Juliana Gebb

First-trimester 3-dimensional power Doppler of the uteroplacental circulation space: a potential screening method for preeclampsia

OBJECTIVE The objective of the study was to compare 3-dimensional power Doppler (3DPD) of the uteroplacental circulation space (UPCS) in the first trimester between women who develop preeclampsia (PEC) and those who do not and to assess the 3DPD method as a screening tool for PEC. STUDY DESIGN This was a prospective observational study of singleton pregnancies at 10 weeks 4 days to 13 weeks 6 days. The 3DPD indices, vascularization index (VI), flow index (FI), and vascularization flow index (VFI), were determined on a UPSC sphere biopsy with the virtual organ computer-aided analysis (VOCAL) program. RESULTS Of 277 women enrolled, 24 developed PEC. The 3DPD indices were lower in women who developed PEC. The area under the receiver-operating characteristics curve for the prediction of PEC was 78.9%, 77.6%, and 79.6% for VI, FI, and VFI, respectively. CONCLUSION Patients who develop PEC have lower 3DPD indices of their UPCS during the first trimester. Our findings suggest that this ultrasonographic tool has the potential to predict the development of PEC.

Colour Doppler ultrasound of spiral artery blood flow in the prediction of pre-eclampsia and intrauterine growth restriction.

Pre-eclampsia and intrauterine growth restriction are responsible for significant maternal and fetal morbidity and mortality worldwide. Identifying pregnancies at highest risk for their development would allow increased surveillance in individual pregnancies and also allow therapeutic trials to decrease their incidences in the future. To date, multiple attempts to develop a screening test for these disorders have met with limited success. Proposed screening methods have included maternal serum biochemical parameters as well as ultrasonographic markers. Uterine artery Doppler, direct evaluation of the spiral arteries using colour and spectral Doppler, three-dimensional placental volume analysis and, most recently, three-dimensional power Doppler angiography have all been suggested. Although an adequate screening method remains elusive, advances in ultrasound technology have improved our ability to observe the pathophysiologic changes that occur with these conditions early in pregnancy, bringing us closer to a reproducible screening model.

Should the first-trimester aneuploidy screen be maternal age adjusted? Screening by absolute risk versus risk adjusted to maternal age

To compare the absolute risk (AR) screening approach to the current approach of risk adjusted to maternal age in patients undergoing first‐trimester screening (FTS).

Long-term neurologic outcomes after common fetal interventions

OBJECTIVE Fetal interventions have clearly decreased mortality, but the neurological outcomes of survivors are of critical concern. Here we consolidated available data on long-term neurological outcomes after common fetal interventions to guide counseling, management, and future research. STUDY DESIGN Published studies assessing long-term neurological outcomes after common fetal interventions from 1990 through 2014 were collected. We included all studies with a cohort of more than 5 patients and with follow-up of 1 year or longer. We divided procedures into those performed for singletons and for multiples. Singleton procedures included amnioinfusion for preterm premature rupture of membranes, intrauterine transfusion for red cell alloimmunization-associated anemia, intrauterine transfusion for parvovirus-associated anemia, vesicoamniotic shunts, thoracoamniotic shunts, ventriculoamniotic shunts, fetal endoscopic tracheal occlusion for congenital diaphragmatic hernia, and open fetal cases by myelomeningocele and others. Multiple procedures included those done for monochorionic twins including serial amnioreduction, selective fetoscopic laser photocoagulation, and selective termination. RESULTS Of 1341 studies identified, 28 met the inclusion criteria. We combined available literature for all procedures. Studies varied in their length of follow-up and method of assessing neurological status. Neurological outcome after intervention varied by procedure but was normal in 40-93%, mildly impaired in 3-33%, and severely impaired in 1-40%. Follow-up to school age was rare with the exception of procedures for monochorionic twins. CONCLUSION Fetal treatments have been successful in achieving survival in previously hopeless cases, but success should also be determined by the outcomes of survivors. Except for monochorionic twins, there is a dearth of reported long-term outcomes. Standardized reporting of long-term neurological sequelae is imperative so that meaningful analysis and study comparisons can be made.

Detection of genetic abnormalities by using CVS and FISH prior to fetal reduction in sonographically normal appearing fetuses

To examine the ability of chorionic villus sampling (CVS) and fluorescence in situ hybridization (FISH) to detect aneuploidy before first trimester fetal reduction (FR) in sonographically normal‐appearing fetuses.

Evolution of gender options in multiple pregnancy management

Fetal reduction (FR) in multiples dramatically improves outcomes. We prioritize FR decisions for health and historically declined to factor gender. As male preferences apparently diminished, our bioethicist encouraged a re‐evaluation.

Clinical Outcomes of Anterior Compared With Posterior Placenta Accreta

INTRODUCTION: The objective of this study was to evaluate the effect of placental location on maternal and gestational outcomes associated with placenta accreta. METHODS: We conducted a retrospective analysis of all cases of pathologically proven placenta accreta with delivery after 20 weeks of gestation at our institution over the past 10 years. Placental location was characterized as anterior or nonanterior. Central previa location was considered in the anterior group. Gestational age at delivery and maternal data were collected. Outcomes of patients diagnosed with anterior accretes were compared with those of patients diagnosed with nonanterior accretes. Composite maternal morbidity was defined as nonred blood cell product transfusion, disseminated intravascular coagulation, or intensive care unit admission or postpartum stay longer than 7 days. RESULTS: The overall incidence of placenta accreta was 1.2 per 1,000 deliveries with 51 confirmed cases. Thirty-one (60.8%) had anterior and 20 (39.2%) had nonanterior placentation. Patients with anterior accretes were more likely to be antenatally diagnosed (58% compared with 17%, P=.003), had a history of more cesarean deliveries (P=.04), and deeper invasion of chorionic villi (P=.004). Composite maternal morbidity was significantly higher (71% compared with 30%, P=.007) and mean gestational age at delivery was lower (33.3 compared with 36.6 weeks, P=.02) for patients with anterior placenta accreta. CONCLUSION: Nearly 40% of accreta cases at our academic institution had nonanterior location. These cases are more difficult to diagnose antenatally but also seem to have less associated morbidity. Anterior placenta accreta appears to be a more histologically and clinically severe disease than posterior placenta accreta with significantly higher maternal morbidity and preterm delivery despite improved antenatal detection.

Clinical outcomes and efficacy of antenatal diagnosis of placenta accreta using ultrasonography and magnetic resonance imaging.

INTRODUCTION: The objective of this study was to evaluate the effect of antepartum diagnosis of placenta accreta on maternal and neonatal outcomes. Additionally, we evaluated the relative contribution of ultrasonography and magnetic resonance imaging (MRI) to antepartum diagnosis. METHODS: We conducted a retrospective analysis of pathologically proven placenta accreta with delivery after 20 weeks of gestation at our institution over the past 10 years. Characteristics and outcomes of patients with antepartum diagnosis were compared with those with intrapartum diagnosis. Referrals for MRI were per health care provider preference. Composite morbidity was defined as nonred blood cell product transfusion, disseminated intravascular coagulation, or intensive care unit admission or postpartum stay longer than 7 days. RESULTS: Twenty-one patients (41%) had antepartum diagnosis and 30 (59%) had intrapartum diagnosis. Antepartum diagnosis was more likely if the placental was previa (76% compared with 40%, P=.025), anterior (58% compared with 15%, P=.003), or both and was significantly associated with deeper invasion of chorionic villi (62% compared with 20%, P=.003), yet we found no difference in composite maternal morbidity. There was increased preterm delivery (P=.03) and lower average birth weights (P=.046) in patients with antepartum diagnosis. Sixty-six percent of antepartum diagnosis patients had MRI. When compared with ultrasonography, MRI was more consistent with the clinicopathologic findings in 7 of 14 (50%) and ultrasonography was more consistent in 7 of 14 (50%) of patients. CONCLUSION: The clinical presentation of placenta accreta is heterogenous and the majority of diagnoses are still made in the intrapartum period. Antepartum diagnosis is associated with higher disease burden and yet allows for equalization of maternal outcomes. Magnetic resonance imaging is of questionable benefit; however, it may be useful in select cases.

Going With the Flow: An Aid in Detecting and Differentiating Bronchopulmonary Sequestrations and Hybrid Lesions

To assess the ability of prenatal ultrasound (US) in identifying systemic feeding arteries in bronchopulmonary sequestrations and hybrid lesions and report the ability of US in classifying bronchopulmonary sequestrations as intralobar or extralobar.

Simultaneous endometrial aspiration and sonohysterography for the evaluation of endometrial pathology in women aged 50 years and older.

OBJECTIVE: To evaluate the performance of simultaneous endometrial aspiration at the time of sonohysterography for screening postmenopausal women at risk for endometrial cancer. METHODS: A retrospective cohort study of women older than 50 years who underwent saline-infusion sonohysterography for the evaluation of their endometrium. On completion of imaging, the remaining intracavitary saline and endometrial tissue were aspirated through the saline-infusion sonohysterography catheter and submitted for pathologic evaluation. Based on the clinical, pathologic, and ultrasonographic results, the patients underwent surgical treatment with hysteroscopy, hysterectomy, or clinical observation. Follow-up results and outcomes were collected using electronic medical records. Sensitivity, specificity, and predictive values of saline-infusion sonohysterography, endometrial aspiration, and combined approaches for endometrial aspiration and sonohysterography were assessed. RESULTS: Six hundred three patients underwent endometrial aspiration at the time of sonohysterography. Endometrial tissue was present in 567 (94.0%) and outcome data were available for 540 (89.5%). In 194 (35.9%) patients, final pathology was obtained by surgical intervention. The remaining 346 (64.1%) patients were monitored for at least 6 months. Thirty patients (5.6%) had cancer or endometrial hyperplasia. A sequential model, in which endometrial aspiration was done only for positive saline-infusion sonohysterography findings, yielded sensitivity of 86.7% (95% confidence interval [CI] 69–96%) and specificity of 100% (95% CI 99–100%) for detecting endometrial hyperplasia or cancer (area under the curve 0.93). Considering proliferative endometrium as abnormal endometrial aspiration reduced specificity to 88.3% (95% CI 85–91%, P<.01) without significant increase in sensitivity (100%, 95% CI 88–100%, P=.13). CONCLUSION: The high sensitivity and specificity of the sequential endometrial aspiration at the time of sonohysterography make this approach a useful and reliable screening algorithm for detecting endometrial cancer or hyperplasia in postmenopausal women at risk. Endometrial aspiration at the time of sonohysterography should be considered as an initial one-stop endometrial evaluation in this population. LEVEL OF EVIDENCE: II